Home Health ICD-9/ICD-10 Alert

Question: When is it appropriate to list a trauma code as a primary diagnosis? Our RHHI has issued education that informs us that home health agencies have been using these codes incorrectly, but I want to make sure we're receiving the full case mix points that we deserve for treating patients with traumatic injuries.

Massachusetts Subscriber


Answer: Code a trauma wound as primary when the focus of care is the care of the wound and the wound was actually caused by trauma. Never code an open wound code for a wound that was not caused by trauma.

In addition, superficial injuries such as skin tears may be caused by trauma but ordinarily only require simple wound care. Simple wound care does not require the skills of a nurse. You'll find the codes for superficial injury in the alphabetic index under "injury, superficial."

If the skin tear is complicated by infection or an underlying condition that will delay healing, there are circumstances in which you may code that wound as a trauma wound. Payment will depend on your documentation, as always.